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1 - 20 of 1849
Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2022;78:623-645.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Lo L, Rotteau L, Shojania KG. BMJ Open. 2021;11:e055247.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic technique used to avoid communication failures during handoffs. This systematic review found that fidelity with SBAR is highest in classroom settings, but that studies in clinical contexts either did not achieve sufficient improvements in fidelity or did not assess fidelity.

Dean J, Subbe C, eds. Future Healthc J. 2021;8(3):e559-e618.

Full realization of the patient voice as a resource for safety is challenging. This special section provides global perspectives examining cultural, organizational, and system-focused opportunities to fully use patient knowledge in improvement initiatives.

Newcastle upon Tyne, UK: Care Quality Commission; September 2021.

The safety of maternity care is threatened by inequity. This report analyzes a set of United Kingdom investigation reports to identify issues affecting maternity care to determine their prevalence elsewhere in the system. Problems identified include poor leadership and teamwork, as well as learning and cross-service collaboration.
Draus C, Mianecki TB, Musgrove H, et al. J Nurs Care Qual. 2022;37:110-116.
“Second victims” are healthcare providers who experience negative feelings in their personal or professional lives after being involved in unanticipated adverse patient events. One hundred and fifty-nine nurses at one American hospital reported being a second victim and experiencing psychological and/or physical distress following the incident.
McGaughey J, Fergusson DA, Van Bogaert P, et al. Cochrane Database Syst Rev. 2021;11:CD005529.
Rapid response systems (RRS) and early warning systems (EWS) are designed to detect patient deterioration and prevent cardiac arrest, transfer to the intensive care unit, or death. This review updates the authors’ review published in 2007. Eleven studies representing patients in 282 hospitals were reviewed to determine the effect of RRS or EWS on patient outcomes.

Gebeloff R, Thomas K, Silver-Greenberg J. New York TimesDecember 9, 2021.

Nursing homes harbor numerous challenges to patient safety and they should be transparently reported and acted upon to ensure improvement. This news investigation discusses a gap in the reporting and inspection of nursing home incidents that undermines the ability of the US nursing home rating system to inform consumer long term care facility choice.
Brenner MJ, Boothman RC, Rushton CH, et al. Otolaryngol Clin North Am. 2021;55.
This three-part series offers an in-depth look into the core values of honesty, transparency, and trust. Part 1, Promoting Professionalism, introduces interventions to increase provider professionalism. Part 2, Communication and Transparency, describes the commitment to honesty and transparency across the continuum of the patient-provider relationship. Part 3, Health Professional Wellness, describes the impact of harm on providers and offers recommendations for restoring wellness and joy in work.
Hannawa AF, Wu AW, Kolyada A, et al. Patient Educ Couns. 2022;105:1561-1570.
In this qualitative study, researchers explore physician, nurse, and patient perspectives about what features constitute “good” and “poor” care episodes. Participants highlighted the importance of quickly identifying and responding to errors and failures as one key component of good quality care.
Jomaa C, Dubois C‐A, Caron I, et al. J Adv Nurs. 2022;78:2015-2029.
Nurses play a critical role in ensuring patient safety. This study explored the association between the organization of nursing services and patient safety incidents in rehabilitation units. Findings highlight the key role of appropriate nurse staffing in reducing the incidence of events such as falls and medication errors
Attia E, Fuentes A, Vassallo M, et al. Am J Health Syst Pharm. 2022;79:297-305.
Anti-coagulants are classified as high-risk medications due to their potential to cause serious patient harm if not administered correctly. This hospital created a multidisciplinary anticoagulant safety taskforce to reduce errors and improve patient safety. The article describes the implementation process, including the use of the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy tool.
Marufu TC, Bower R, Hendron E, et al. J Pediatr Nurs. 2022;62:e139-e147.
Medication errors threaten patient safety and can result in adverse outcomes. This systematic review identified seven types of nursing interventions used to reduce medication administration errors in pediatric and neonatal patients: education programs, medication information services, clinical pharmacist involvement, double checking, barriers to reduce interruptions during drug calculation and preparation, use of smart pumps, and improvement strategies (e.g., checklists, process or policy changes). Meta-analysis pooling results from various types of interventions demonstrated a 64% reduction in medication administration errors.
Okpalauwaekwe U, Tzeng H-M. Patient Relat Outcome Meas. 2021;12:323-337.
Patients transferred from hospitals to skilled nursing facilities (SNFs) are vulnerable to adverse events. This scoping review identified common extrinsic factors contributing to adverse events among older adults during rehabilitation stays at skilled nursing facilities, including inappropriate medication usage, polypharmacy, environmental hazards, poor communication between staff, lack of resident safety plans, and poor quality of care due to racial bias, organizational issues, and administrative issues.
Tzeng H-M, Raji MA, Chou L-N, et al. J Nurs Care Qual. 2021;37:6-13.
Potentially inappropriate medications (PIMs) for older adults carry a high risk of adverse drug events. Using a sample of Medicare beneficiaries from 2015 to 2018, researchers assessed the impact of state scope of practice regulations for nurse practitioners (NPs) on PIM prescribing patterns compared to primary care physicians. Findings indicate that the PIM prescribing rate is lower in states with full NP practice and lower among NPs than among physicians.
Berwick DM. JAMA. 2021;326:2127-2128.
Efforts to improve diagnosis recognize the value in patient-centered care. This commentary outlines how a diagnostician can enfold patient centeredness into their practice, which includes the seeking of knowledge and moderation of actions taken to arrive at a diagnosis. This piece is part of a series on diagnostic excellence.

Ackerman RS, Patel SY, Costache M, et al. Anesthesiology News. November 21, 2021.

Blame is known to limit discussions of near-misses and failures, which negatively impacts learning and incident reduction. This article describes work to examine blameful context present in anesthesiology incident documentation, reducing its viability as a successful investigation record. Length of text was identified as an enabler of blameful orientation, and limitations as to word count were one strategy to minimize the use of punitive language.